Roser Terradas

Eosinophil Count and Neutrophil-Lymphocyte Count Ratio as Prognostic Markers in Patients with Bacteremia: A Retrospective Cohort Study

Introduction There is scarce evidence on the use of eosinophil count as a marker of outcome in patients with infection. The aim of this study was to evaluate whether changes in eosinophil count, as well as the neutrophil-lymphocyte count ratio (NLCR), could be used as clinical markers of outcome in patients with bacteremia. Methods We performed a retrospective study of patients with a first episode of community-acquired or healthcare-related bacteremia during hospital admission between 2004 and 2009. A total of 2,311 patients were included. Cox regression was used to analyze the behaviour of eosinophil count and the NLCR in survivors and non-survivors. Results In the adjusted analysis, the main independent risk factor for mortality was persistence of an eosinophil count below 0.0454·103/uL (HR = 4.20; 95% CI 2.66–6.62). An NLCR value >7 was also an independent risk factor but was of lesser importance. The mean eosinophil count in survivors showed a tendency to increase rapidly and to achieve normal values between the second and third day. In these patients, the NLCR was <7 between the second and third day. Conclusion Both sustained eosinopenia and persistence of an NLCR >7 were independent markers of mortality in patients with bacteremia.

Moisturizing body milk as a reservoir of Burkholderia cepacia: outbreak of nosocomial infection in a multidisciplinary intensive care unit

BackgroundAn outbreak of severe nosocomial Burkholderia cepacia infections in patients admitted to intensive care unit (ICU), including investigation of the reservoir, is described.MethodsOver a period of 18 days, isolates of Burkholderia cepacia were recovered from different biological samples from five patients who were admitted to a multidisciplinary 18-bed intensive care unit. Isolation of B. cepacia was associated with bacteraemia in three cases, lower respiratory tract infection in one and urinary tract infection in one. Contact isolation measures were instituted; new samples from the index patients and adjacent patients were collected; and samples of antiseptics, eau de Cologne and moisturizing body milk available in treatment carts at that time were collected and cultured.ResultsB. cepacia was isolated from three samples of the moisturizing body milk that had been applied to the patients. Three new hermetically closed units, from three different batches, were sent for culture; two of these were positive as well. All strains recovered from environmental and biological samples were identified as belonging to the same clone by pulsed-field gel electrophoresis. The cream was withdrawn from all hospitalization units and no new cases of B. cepacia infection developed.ConclusionMoisturizing body milk is a potential source of infection. In severely ill patients, the presence of bacteria in cosmetic products, even within accepted limits, may lead to severe life-threatening infections.

High Prevalence of Extended-spectrum Beta-lactamase-producing Enterobacteriaceae in Bacteremia After Transrectal Ultrasound-guided Prostate Biopsy: A Need for Changing Preventive Protocol

OBJECTIVES To determine whether the incidence of bacteremia after transrectal ultrasound-guided prostate biopsy (TRUSGPB) significantly diminishes with the setting up of a new preventive protocol. This protocol was set up after detecting an augmented incidence of bacteremia after TRUSGPB with a high prevalence of antibiotic-resistant microorganisms. METHODS Retrospective descriptive and prospective intervention study performed at a University Hospital. PARTICIPANTS Patients undergoing TRUSGPB under the old preventive protocol (January 2006-February 2007), that is, amoxicillin-clavulanate 500 mg tid the day before, the day of the procedure, and 1 day after the procedure, and after setting up a new protocol (March 2007-April 2008), that is, 2 g cefoxitin 1 hour before the procedure and ciprofloxacin 750 mg p.o. bid the day before, the day of the procedure, and 3 days after the procedure; dipstick urinalysis was performed before the procedure, and patients with positive results were not biopsied. RESULTS Incidence of bacteremia with old and new protocols: 9 of 204 procedures (4.4%) vs 2 of 207 (0.9%), (P = .03). Four isolates (44.4%) under the old protocol produced extended-spectrum beta-lactamase (ESBL). With the new protocol, 2 (0.9%) cases of non-ESBL Escherichia coli bacteremia were observed. Sixty-five (23.8%) cases were not biopsied because of positive result of dipstick urinalysis, lack of antibiotic prophylaxis adherence, or altered coagulation parameters. CONCLUSIONS Antibiotic prophylaxis for TRUSGPB should take into account local resistance patterns. Cefoxitin could be used as prophylaxis in centers with high prevalence of ESBL enterobacteriaceae. Before TRUSGPB, excluding patients with positive results of dipstick urinalysis is an advisable practice.

Clinical characteristics and outcomes of patients with vancomycin-susceptible Enterococcus faecalis and Enterococcus faecium bacteraemia in cancer patients

The purpose of this investigation was to compare the risk factors, clinical features and outcomes in cancer patients with bacteraemia caused by vancomycin-susceptible Enterococcus faecalis and E. faecium. A retrospective, observational 7-year study was carried out in a 450-bed, acute-care university-affiliated hospital. We performed univariate comparisons between the two groups and then multivariate analysis to identify patient risk factors for E. faecium isolation. Seventy-three patients were included in the analysis: 54 (74.0%) with bacteraemia caused by E. faecalis and 19 (26.0%) by E. faecium. The Simplified Acute Physiological Score (SAPS) value was significantly greater in E. faecium isolates (40.7 vs. 35.2; p = 0.009). Diabetes mellitus was more frequently diagnosed in patients with E. faecium bacteraemia (52.6% vs. 24.1%; p = 0.021). Prior penicillin exposure was more frequent in patients with E. faecium bacteraemia (68.4% vs. 29.6%; p = 0.003). There was a trend toward higher mortality in E. faecium bacteraemia patients (47.4% vs. 25.9%; p = 0.084). Independent patient risk factors for E. faecium isolation were prior penicillin exposure (odds ratio [OR], 6.479; p = 0.003) and SAPS > 34 (OR, 6.896; p = 0.009). When compared to E. faecalis bacteraemia, E. faecium bacteraemia in cancer patients is independently associated with more severe illness and prior use of penicillins; therefore, empiric treatment which would cover E. faecium should be considered in cancer patients suspected of having bacteraemia.

Características clínicas diferenciales entre las bacteriemias por Enterococcus faecalis y Enterococcus faecium

INTRODUCTION Enterococci are responsible for severe infections, such as endocarditis and bacteremia. During recent decades, enterococcal infections have grown in importance because of the increasing number of cases. Knowledge of the factors predisposing to acquisition of infection by E. faecalis or E. faecium may be useful to improve the empirical treatment. METHODS Retrospective study of patients diagnosed with enterococcal bacteremia and hospitalized over a 7-year period (January 2000-December 2006), analyzing demographic data, clinical and microbiological characteristics, antibiotic exposure, treatment, and outcome. To identify the predisposing factors for isolation of E. faecalis or E. faecium in a clinical specimen, we performed univariate comparisons between the 2 groups, and subsequently, multivariate logistic regression analysis. RESULTS A total of 228 episodes of bacteremia were recorded, 168 caused by E. faecalis and 60 by E. faecium. All E. faecalis isolates were susceptible to ampicillin, but only 25% of E. faecium were ampicillin-susceptible. There was only 1 vancomycin-resistant isolate. The variables independently associated with acquisition of E. faecium bacteriemia were surgical ward admission (odds ratio [OR], 4.223; P=.001), >5 days of previous treatment with cephalosporins (OR, 2.564; P=.013), >5 days of carbapenems (OR, 2.652; P=.027), previous administration of penicillins (OR, 2.008; P=0.044), SAPS score >30 at admission (OR, 3.530; P=0.001), and hepatobiliary disease as a comorbid condition (OR, 3.754; P<0.001), CONCLUSION Because of the differing susceptibility patterns of the enterococcal species studied, it is essential to know the factors predisposing to acquisition of infection by one or the other species to initiate adequate empirical treatment.

Bacteriemia comunitaria tratada o identificada de forma ambulatoria tras el alta de un servicio de urgencias

Fundamento y objetivo Los pacientes con bacteriemia suelen requerir ingreso hospitalario, aunque en ocasiones se les remite a su domicilio por diagnostico inapropiado o rapida mejoria. En el presente estudio se describen la evolucion y las intervenciones realizadas en los pacientes con bacteriemia comunitaria remitidos a domicilio. Pacientes y metodo Estudio prospectivo realizado en un hospital de 450 camas desde marzo de 2000 hasta diciembre de 2003. El centro dispone de un equipo que controla todas las bacteriemias. Se identifico a los pacientes enviados a su domicilio desde urgencias y que recibieron tratamiento antimicrobiano inapropiado. Resultados Se diagnostico a 1.172 pacientes con bacteriemia verdadera, de los que 247 (21,1%) fueron remitidos a su domicilio. En 50 casos (20,2%) se considero necesario revaluar al paciente: 36 por tratamiento antibiotico inapropiado, 12 sin tratamiento antibiotico y 2 por falta de informacion. En 34 pacientes (64%) se instauro o modifico el tratamiento antimicrobiano y 10 (20%) requirieron ingreso hospitalario. Excluyendo a los 66 pacientes que fallecieron en las primeras 48 h, la mortalidad bruta de los pacientes remitidos a domicilio fue inferior (4%) a la de los pacientes ingresados (11,9%). Conclusiones Una quinta parte de las bacteriemias comunitarias fueron tratadas de forma ambulatoria. Con frecuencia el tratamiento antibiotico fue inapropiado. Es necesario garantizar un control adecuado de estos pacientes.

Cost attributable to nosocomial bacteremia. Analysis according to microorganism and antimicrobial sensitivity in a University Hospital in Barcelona.

Aim To calculate the incremental cost of nosocomial bacteremia caused by the most common organisms, classified by their antimicrobial susceptibility. Methods We selected patients who developed nosocomial bacteremia caused by Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, or Pseudomonas aeruginosa. These microorganisms were analyzed because of their high prevalence and they frequently present multidrug resistance. A control group consisted of patients classified within the same all-patient refined-diagnosis related group without bacteremia. Our hospital has an established cost accounting system (full-costing) that uses activity-based criteria to analyze cost distribution. A logistic regression model was fitted to estimate the probability of developing bacteremia for each admission (propensity score) and was used for propensity score matching adjustment. Subsequently, the propensity score was included in an econometric model to adjust the incremental cost of patients who developed bacteremia, as well as differences in this cost, depending on whether the microorganism was multidrug-resistant or multidrug-sensitive. Results A total of 571 admissions with bacteremia matched the inclusion criteria and 82,022 were included in the control group. The mean cost was € 25,891 for admissions with bacteremia and € 6,750 for those without bacteremia. The mean incremental cost was estimated at € 15,151 (CI, € 11,570 to € 18,733). Multidrug-resistant P. aeruginosa bacteremia had the highest mean incremental cost, € 44,709 (CI, € 34,559 to € 54,859). Antimicrobial-susceptible E. coli nosocomial bacteremia had the lowest mean incremental cost, € 10,481 (CI, € 8,752 to € 12,210). Despite their lower cost, episodes of antimicrobial-susceptible E. coli nosocomial bacteremia had a major impact due to their high frequency. Conclusions Adjustment of hospital cost according to the organism causing bacteremia and antibiotic sensitivity could improve prevention strategies and allow their prioritization according to their overall impact and costs. Infection reduction is a strategy to reduce resistance.

Resultados de un proyecto multidisciplinar y multifocal para la disminución de la bacteriemia causada por catéter venoso central, en pacientes no críticos, en un hospital universitario

OBJECTIVE To evaluate a multidisciplinary and multifocal intervention in order to reduce catheter related bloodstream infections (CRBI), based on previously identified risk factors in non-critical patients. METHODS A pre-post-intervention study, 2004-2006. POPULATION patients with a central venous catheter (CVC). The primary endpoint was the CRBI. Other studied variables were patient characteristics, insertion, maintenance and removal of the catheter. The intervention consisted of baseline knowledge and identifying risk factors. In a second period, there was specific training on these identified risk factors and communication of the results, monitoring and evaluation of the CVC inserted. RESULTS We analysed 175 and 200 CVC, respectively. The incidence of CRBI was 15.4% during the pre-intervention and 4.0% in the post-intervention period (P<.001). The incidence of BRC by CVC days in the first group was 8.8 infections 1.000 days of CVC and the second 2,3 (P=.0009). The multivariate analysis found an increased risk of CRBI during the first period (OR 4.32; 95% CI: 1.81-10.29) and the use of total parenteral nutrition (OR: 2.37; 95% CI: 1.10-5. 12). CONCLUSION The application of specific measures directed at all non-critical patients in the entire hospital and involving a large number of professionals has achieved a decrease incidence of 73.9% of CRBI. An acceptable incidence of CRBI was obtained, and, with the completion of the project together with a new awareness, the situation will continue to improve.

Characterization and rapid control of a vancomycin-resistant Enterococcus faecium (VREF) outbreak in a renal transplant unit in Spain: The environment matters.

OBJECTIVE To describe a clonal outbreak due to vancomycin-resistant Enterococcus faecium (VREF) in the nephrology and renal transplant unit of a tertiary teaching hospital in Barcelona, Spain, and to highlight how active patient and environment surveillance cultures, as well as prompt and directed intervention strategies, mainly environmental, helped to successfully bring it under control. PATIENTS AND METHODS A study was conducted on patients admitted to the nephrology ward with any culture positive for VREF over a 6-month period (August 2012-January 2013). Based on the identification of a clonal link between the isolates, weekly rectal screening using swabs was implemented for all patients, as well as environmental cultures and cleaning of medical equipment and the ward. VREF isolates were identified by MicroScan and confirmed by Etest. Bacterial identification was confirmed by MALDI-TOF MS. The presence of van genes, and esp and hyl virulence genes was determined using PCR. The clonal relationship between the isolates was studied first with DiversiLab (bioMérieux), and then by PFGE-Smal and MLST. A two-tier sequence of infection control measures was implemented. RESULTS During the study period, VREF was isolated from 13 patients. All cases were colonized with no criteria for infection. VREF isolates were also extensively recovered from the environment and medical equipment. Isolates carried the vanA gene, and were multidrug-resistant, including high-level resistance (MIC >16mg/L) to vancomycin and teicoplanin. Molecular analysis showed that all VREF isolates belonged to sequence type 17 (ST17) carrying hyl virulence genes. After implementing infection control measures in a two-tier sequence, and reinforcing particularly environmental and medical equipment cleaning, no further cases were detected in the follow-up year. CONCLUSION A clonal outbreak of VREF-ST17 involving only colonization is reported. The prompt implementation of aggressive infection control measures in patients and the environment was effective in controlling the outbreak and avoided the potential emergence of infection among patients.

Original articleCharacterization and rapid control of a vancomycin-resistant Enterococcus faecium (VREF) outbreak in a renal transplant unit in Spain: The environment mattersCaracterización y control rápido de un brote de Enterococcus faecium resistente a vancomicina en una unidad de trasplantados renales en España: el ambiente importa

Objective To describe a clonal outbreak due to vancomycin-resistant Enterococcus faecium (VREF) in the nephrology and renal transplant unit of a tertiary teaching hospital in Barcelona, Spain, and to highlight how active patient and environment surveillance cultures, as well as prompt and directed intervention strategies, mainly environmental, helped to successfully bring it under control.